2005-11-14_REPORT - M1992113

• Permit No: M1992113
• IBM Index Class Name: Report
• Doc Date: 11/14/2005
• Doc Name: Annual Fee/Report/Map
• From: Bent County
• To: DMG
• Media Type: D
• Archive: No

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PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNNERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
AN~NIiAi, FF.F, and RF,PORT RF.QITFST
B nt County
-1992-113
Verhoeff Pit No 2
December 17, 2005
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4
~OU 1 ~ 2005
/ "Division ct R".ir.cral~ C: C-oclc(iV
$688.00 (Due on or before your anniversary date)
Bent
According to C.R.S. 34-32.5-116 or C.R.S. 34-32-116, each year, on the anniversary date of the permit, an
operator shall submit the annual fee, a report and map showing the extent of current disturbances to affected
land, reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to
occur during the upcoming year, reclamation that will be performed during the coming year, the dates for the
beginning of active operations, and the date active operations ceased for the year, if any.
Please attach ypnr revised written anm~al reanrf and annnal rr orn t mar this form. please note thal an
adequately labeled map that clearly delineates and includes the above elements may since for a written
report.
Division records indicate the following permittee contact information. Please verify and make any necessary
changes:
Permittee Contact: Gary Pritchard
Permittee Name;
Address:
Bent County
P.O. Box 350
Las Animas, CO 81054-0350
Phone Nurnber: [phone]
Fax Number: [phone]
If you have additional comments and/or information that should be provided to the Division, please provide it
below or attach it to this form along with your written report and map. Annual Report instructions are
enclosed.
'~i~..~_.b,
Signature of Corporate Officer, O ner, or Designee
11 -0'7 -ao~os
Date
M:~PERMI7~MASTERD000MENTS4M-AF-04